Suicide Prevention in Systems

I've been working for several years on how to represent the key elements of Suicide Prevention in Systems, which is often referred to as Zero Suicide. And the concept of Zero Suicide emerged about 15 years ago or so, inspired by efforts to reduce negative outcomes in healthcare, drawing on principles from patient safety. So, seminal work called this approach Suicide Care in Systems Framework, and the idea was to widen the lens around preventing suicide from just focusing on the dyad of the clinician and patient, which is really most of how we thought of it at that time, to thinking about how the system can support care that leads to the best outcomes for people and the safest approach. Early on, several key concepts of Zero Suicide emerged, and these were eventually encapsulated by keywords, Lead, Train, Identify, Engage, Treat, Transition, and Improve. These helpful terms became the hallmark of what it meant to pursue Zero Suicide.

At SafeSide Prevention, we're agnostic about whether you choose to frame or name your initiative Zero Suicide, and whether you use these specific terms. So we're happy to work with systems regardless of how they're using that language. To maintain this flexibility, we call our approach Suicide Prevention in Systems. Over the past four years or so, my colleagues and I have been evolving this diagram to operationalize and hopefully add greater substance to capture what's critical in a systems approach to suicide. Those original terms of Lead, Engage, Train, they're still useful, but we wanted to add meaning and specificity to guide organizations in developing and selecting their programming and activities. This diagram breaks down the approach into three core domains: Culture, Practice, and Education and Development. At the end of this video, I'll show you how the original Zero Suicide keywords map onto this schema. Culture of Safety and Prevention. These are really the organizational foundations, and what could be more foundational than the people of an organization? So the first is to promote connected, safe, and resilient workplace relationships. A healthy, cohesive, and well-connected workforce is essential for conveying health and wellness to the people that the organization is aiming to serve. Though if people in an organization feel disconnected, or unsafe, or there are unhealthy norms in the system, it'll be much harder to pass on health and wellness to the people the organization's engaged with. SafeSide Prevention’s Connect Program, initially developed and tested by my close colleague Peter Wyman and our team at the University of Rochester with the US Air Force, aims to build cohesion, healthy norms, and morale among people in various settings. The Air Force in many places actually resembles an office or a manufacturing environment, making it essentially a workplace. We conducted a randomized trial and are in the process of a second trial and validating the program in other settings, including with police, African-American churches, and urban adolescent males involved in sports. Regardless of the exact programs and initiatives you use, we encourage organizations interested in pursuing suicide prevention to ask themselves how they're promoting a connected, safe, and resilient workforce. Lived experience integrated into culture, practice, and education.

Truly integrating lived experience into all aspects of a system is crucial for effective suicide prevention. Most organizations would agree that involving people with lived experience is important, I mean, nobody is going to disagree with that. But just believing this is not the same as fully integrating it into leadership, service design and education. So we really encourage organizations to think about how lived experience could be represented in teams working on Suicide Prevention in Systems or Zero Suicide initiatives. It's hard to imagine teams being effective unless this experience is truly involved in leading the design of services and pathways and education. Improving the responsiveness of services, ensuring that education is targeted in the right way with the right approach and heart, really requires the perspective of those who've been affected by suicide. Now, it's important to involve both people who have engaged with your service, as well as, those who have avoided seeking care.

I'm thinking particularly of healthcare kinds of organizations right now, and it's very common for advisory boards or, kind of, people who are involved to have been people who themselves benefited from the care provided in the system. Now, while that's important, if you only include service users, you'll miss the perspective and insights of people who haven't been coming because maybe of some of the ways that the services aren't meeting the needs of some people in your community. So engaging with the community to really try to find people who have lived experience but aren't engaging with healthcare service. That’s challenging, but I think it's necessary to get this perspective. The SafeSide Prevention programs are co-taught, co-led, and co-developed with people with lived experience, those who have sought care as well as those who haven't, and there are other concrete steps organizations can take to build capacity for lived experience involvement, including, but not limited to, funding paid positions to recognize the value of their contributions. Restorative, just, and learning culture and post-incident process. A restorative, just, and learning approach to reviewing suicide related events focuses on who's been hurt or impacted and what they need. Promoting, healing, learning, and improving.

Many of us who have experienced suicide loss in the professional context will tell you that, and this was certainly true for me, the administrative responses and reviews that follow an incident often add to rather than promoting healing from the trauma of the incident itself. And that goes not just for clinicians, but for families and others impacted. In many ways, our review processes are insufficient and sometimes harmful. My close and dear colleague, Dr. Kathy Turner, a leader in Queensland Health, wrote a paper with a really provocative and excellent title, “The Inconvenient Truths of Zero Suicide,” and in that paper, she suggests that it's almost unethical to call people to a bold goal like Zero Suicide unless we're really going to be there for people if suicide does occur. This insight really resonated with me and impacted me, and it's one of those things that once you see it, it's really hard to unsee it. The restorative, just, and learning approach rather than asking what happened, what went wrong, and who's to blame, addresses human hurts and involves impacted clinicians, families, organizational leaders, community in some cases and others. It's not just about what policy wasn't followed, but about recognizing and addressing the needs of all interested parties affected by a suicide or suicide related incident. It doesn't have to be a suicide death. Research is beginning to show that these processes yield better recommendations and buy-in as they involve those who are directly impacted. Though organizations can have processes in place to recognize and address the needs of all affected by suicide or suicide related incident. SafeSide Prevention in partnership with Kathy Turner, Diana Grice, and others at Gold Coast and Metro North Mental Health in Queensland have developed Restore, which is really a program designed for leaders. A learning community and resource library to empower and assist leaders to lead change in strengthening their approach to critical incidents by embedding these principles of restorative, just, and learning culture. This program is evolving to include communication packages, document and process templates, and really we'll all be learning together and continuing to build the resources to promote this kind of approach.

Best practices, policies, and pathways. The first element here is to ensure that practices and pathways that you have promote safety, but not just safety, recovery and health. You can think of those cultural foundations like tilling the soil. Policies and pathways then are the seed of suicide care, and as we'll see, it's supporting the workforce with education and development that waters those seeds. Organizations can examine what their systems are doing in terms of connecting well with people, understanding and assessing their concerns and needs, and responding with personalized interventions and plans that are evidence-based, and really take into account the needs and preferences, context and constraints of the individual and family, and then extending their impact into their lives and networks. This involves looking at how the system connects with people beyond the individual, beyond direct interactions with healthcare facilities, and beyond the person's enrollment in a program or episode of care. SafeSide Prevention encourages organizations to examine their current practices and policies and when invited, join in with that and do that process with them. To look at how policies and procedures might better support best practices in suicide prevention and how those can mutually reinforce education and the culture that you're aiming to promote. Strategies to explore, prepare, implement, and then sustain and scale innovation. This is actually the newest of the elements that has appeared on the diagram, but it's been a big missing element for a number of years. Implementation and communication plans are really at the centerpiece of initiatives, and we now have a couple of decades of really good implementation science, research, structures and frameworks that can inform our work. This research has shown that plans for rolling out changes, whether in practice policy, workforce wellness, restorative culture, they're so critical for success. There need to be clear plans for preparing the environment, communicating effectively, understanding the inner and outer context variables that may be affecting your implementation.

So we give careful thought to how to prepare the environment and develop robust communications plans and assets that can be delivered in sequences and messaged based on what the different priorities of stakeholders are, and establish clear implementation steps. Data-driven continuous quality improvement. Nobody can argue that data collection and quality improvement are essential, but it can be challenging. Organizations can be creative in measuring an evaluation, determining metrics that are going to matter in your organization, even if it's just a few and assuring that they can be collected routinely. At SafeSide Prevention, we encourage organizations to look for data that can be collected without relying solely on time intensive processes of gathering self-report. So we really try to work with organizations to think about what data might be at hand or are there any ways that there are behavioral manifestations of the attitudes, skills, practices, and outcomes that you're looking for. Workforce Education and Development. You can hear by these terms how robust we intend this to be. The term “training,” or “we're going to do a training,” or “train clinicians” really doesn't capture the breadth of investment that's needed in the workforce if we're going to accomplish these bold goals like Zero Suicide. The first element is to have a shared framework and common language across teams, services, and systems. It's hard to overstate how important it is for people to be on the same page, rowing in the same direction with a shared approach and common language for communicating across teams, across services, and ideally across services in a community. Having this common language can really promote collaboration, a more consistent experience for people who move between systems, as many people do. The term “training” can conjure up the wrong ideas about what's needed. People don't just need more information, they need more interaction and application. There are probably many ways to bring people together with a common language and approach. SafeSide Prevention’s Framework for Suicide Prevention provides a map of best practices that services can use to evaluate their work and individual providers can use to think about the care they provide. It serves as a schema for thinking through difficult and complicated problems. This framework can be used as a co-reflect tool for teams, peers, clinicians, with the person that you're working with, trying to bring everybody literally on the same page with a common approach and language. Technical knowledge about a particular practice isn't enough.

People need a way to think about how all the different parts of care fit together so that the whole is greater than the sum of its parts. That's the whole idea behind the Zero Suicide approach. It's that by thinking about how the system works together, we may achieve greater outcomes than just by thinking about individual practice. And education needs to have sustainable ongoing learning and onboarding of new staff into the culture and education. Learning, support and interaction around suicide prevention needs to be ongoing for all of us. This work is so complex and emotionally demanding, and best practices are evolving, so there needs to be ways to continue to keep ourselves up to speed and bring in new people. The education delivery model should be scalable and sustainable, longitudinal. Enabling every new staff member to receive training shortly after coming on the job and keeping existing staff up-to-date, refreshed, supported. My colleagues and I at the University of Rochester and at SafeSide Prevention developed the model of InPlace Learning to try to address some of these needs. It involves online learning that's done as a group, getting people out from behind their computers and interacting together, allowing for discussion and interaction, but without the overhead of an in-person trainer. This approach combines the convenience and fidelity and repeatability of online learning, but adds the opportunity to discuss in a small group setting and talk about how these things apply. Flexibility for adaptation of content and process refers to the principle that education should be adaptable to the local setting, population, and to specific initiatives or geographical areas. This can allow teams to take education as a stimulus for conversation. Remembering that people don't just need information, they need interaction, or they have a framework, demonstrations, and then take those and discuss how they apply or if they apply to their work and the people that they serve.

SafeSide Prevention’s programs are designed with this adaptability in mind, and that adaptation and flexibility ranges from, kind of, a baseline of natural customization that occurs as groups get together and talk about the application of best practices to their environment, to more intensive partnerships with organizations and governments to co-fund and co-develop education tailored to specific initiatives or locations. An example of this that is particularly meaningful to me is SafeSide Prevention's collaboration with a Primary Health Network and a suicide prevention collaborative in the Illawarra Shoalhaven region of New South Wales, Australia. Together, we adapted the core SafeSide program for the Alcohol and Other Drugs sector. By working together in some really beautiful collaborations, the program was customized to meet the community's needs and represent the lived experience of people from that area. This diagram represents our current state of thinking about a systems approach or Zero Suicide approach. We have to understand that nobody has the final model when it comes to suicide prevention. For those working in a Zero Suicide framework, and if you're drawing on those terms that define the approach, Lead, Train, Identify, Engage, Treat, Transition, Improve, you can see here how those terms map on to this systems approach to suicide prevention. So if you find these terms useful for communicating in your particular setting, or maybe you've already been doing so, it's easy enough to continue using these terms. There's no need to change the language. While I've walked through this diagram from left to right, it’s important to remember that Suicide Prevention in Systems is not linear. Initiatives don't move in that same way. All three of these, Culture, Practice, Education, they're interconnected and work together in a comprehensive system-wide approach. In fact, that's why it's so important to have a good implementation strategy so that you're ordering the elements in a way that makes sense for your organization. Thank you for your interest in these evolving ideas. I'd love to hear any questions, comments, challenges, or points of intersection that you have and might want to share with me and our team. That way, we can continue to revise our approaches as we strive to make a meaningful difference in the lives of those affected by suicide.